Citation Nr: 21039892 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 15-05 670 DATE: July 1, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected ischemic heart disease and/or as due to exposure to herbicide agents, is remanded. Entitlement to service connection for kidney disorder, to include calculi of the kidney, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1964 to March 1985, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2011 by a Department of Veterans' Affairs (VA) Regional Office. In April 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In July 2018, the Board remanded the case for additional development and it now returns for further appellate review. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected ischemic heart disease and/or as due to exposure to herbicide agents. The Veteran asserts his currently diagnosed hypertension had its onset during his military service or, in the alternative, is caused or aggravated by his service-connected ischemic heart disease. As pertinent to the former theory of entitlement, the Veteran testified that, in approximately 1974-1975, he began experiencing severe chest pain while a passenger in a car with fellow Marines in upstate New York. He reported that he took some aspirin and, following an EKG at Camp Lejeune a few days later, he was informed that he had a mild heart attack. The Veteran further indicated that he was subsequently placed on a tilt table test, and would go to the dispensary three to four times, sometimes every morning, to have his blood pressure taken. While the Veteran's service treatment records (STRs) are unavailable, a May 1983 service personnel record (SPR) indicates that he had been diagnosed as having a high blood pressure condition for which he was being treated. He further alleges that his hypertension is the result of the stress associated with his position and responsibility in the Marines. Pursuant to the July 2018 remand, the Veteran was afforded a VA examination in March 2021 in order to determine whether his hypertension was related to his military service. In this regard, the examiner opined that such disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of such opinion, he indicated that there were no signs, symptoms, or treatment of hypertension in the reviewed treatment records, and there was no formal blood pressure treatment until the 2000's. In this regard, the examiner indicated that, outside of the synopsis provided in the July 2018 remand, he had not seen the May 1983 SPR. He further explained that tilt table testing was not indicated for the evaluation of hypertension, rather, such is indicated for the evaluation of syncope/fainting. The examiner also provided a list of risk factors for the development of hypertension, to include age, obesity, family history, physical inactivity, elevated sodium diet, and excess alcohol use, and noted that, while he was not able to determine a family history and physical inactivity would not have applied during service, the Veteran was a smoker, which negatively influences blood pressure. Ultimately, he found that the etiology of the Veteran's hypertension was unknown. In light of the examiner's initial inability to locate the May 1983 SPR, he provided an addendum opinion in April 2021 following a review of such document. Specifically, at such time, he again opined that the Veteran's hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of such opinion, the examiner noted that blood pressures can be elevated in an isolated incident. He explained that the Veteran was a smoker and it was plausible that he had an isolated elevated blood pressure reading during a visit in 1983. The examiner also observed that increased weight is a risk factor for hypertension and the reduction of weight is medically shown to improve blood pressure. Nonetheless, he found that the fact remained that the record did not show that the Veteran was treated or officially diagnosed with hypertension until after his separation from service. The examiner also explained that white coat syndrome is a proven phenomenon and can cause isolated elevated blood pressure readings and, thus, the diagnosis of hypertension is done over time. As relevant to the notation of elevated blood pressure in 1983, he stated that it was not reasonable to diagnose a patient on one blood pressure reading. Further, it would have been prudent for the provider to order testing to see the impact of the blood pressure, i.e., if such was causing end organ damage. However, the Board finds that the March/April 2021 VA examiner mischaracterized the May 1983 SPR as showing an isolated elevated blood pressure reading when such, in fact, reflects that he had been diagnosed with a high blood pressure condition and was receiving treatment. Additionally, the examiner did not consider whether the Veteran's hypertension was related to the stress he experienced during service. Thus, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing such matters. In regard to the Veteran's claim that his hypertension is secondary to his service-connected ischemic heart disease, a November 2010 VA examiner opined that such disorder is not likely due to or aggravated by his service-connected ischemic heart disease as ischemic heart disease does not cause hypertension. Rather, she found that his hypertension contributed to his ischemic heart disease as such is a strong risk factor of ischemic heart disease/coronary artery disease. However, as she did not offer a rationale for her determination that the Veteran's hypertension was not aggravated by his ischemic heart disease, a remand is necessary in order to obtain an addendum opinion addressing such matter. Finally, while not alleged by the Veteran, the Board notes that his exposure to herbicide agents based on his service in the Republic of Vietnam has been acknowledged and, while hypertension is not a disease acknowledged to be presumptively related to such exposure, the National Academy of Sciences (NAS) Institute of Medicine (IOM) has concluded there is "sufficient" evidence of an association to exposure to Agent Orange in Update 11 (2018). According to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. Therefore, the Board finds an opinion addressing such theory of entitlement should also be obtained on remand. 2. Entitlement to service connection for kidney disorder, to include calculi of the kidney. The Veteran contends he has a chronic kidney disorder that began during his military service in approximately 1983. Specifically, he alleges that he experienced his first kidney stone at such time and, thereafter, he has experienced kidney stones regularly, about three to four times per year. While he reported seeking treatment at such time, his STRs are unavailable. Nonetheless, as he knew the procedure to pass kidney stones, he self-treated during such episodes and did not seek further medical treatment until December 1998 when he had difficulty passing one. In this regard, a December 1998 treatment record from Kaiser Permanente reflects the Veteran's report of a 15-year history of experiencing kidney stones and a January 1999 record notes a large left proximal ureteral calculus. Moreover, according to a lay statement from the Veteran's former spouse, dated November 2010, she has known the Veteran since 1980 and, for as long as she has known him, he has had ongoing issues with kidney stones. Based on the fact that the Veteran's STRs are unavailable and, in light of his and his former spouse's statements, the Board finds that a remand for a VA examination and opinion is necessary to determine whether a current kidney disorder is related to the Veteran's military service, to include whether calculi of the kidney manifested within one year of discharge from active service. The matters are REMANDED for the following actions: 1. Forward the record to an appropriate clinician other than the March/April 2021 VA examiner, if possible, for an addendum opinion addressing the etiology of the Veteran's hypertension. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension had its onset in, or is otherwise related to, his military service, to include the May 1983 SPR wherein it was noted that he was diagnosed with a high blood pressure condition and was receiving treatment; the stress associated with his position and responsibility in the Marines; and/or his acknowledged in-service exposure to herbicide agents? In offering such opinion, the examiner is advised that the Veteran's STRs are unavailable and no negative inference may be drawn based on such fact. The examiner should also address the NAS IOM Update 11 (2018) in which hypertension was upgraded from its previous classification in the category of "limited or suggestive" evidence of an association with exposure to Agent Orange to the category of "sufficient" evidence of an association. In this regard, according to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension manifested within one year of his separation from service in March 1985, i.e., by March 1986? If so, please describe the manifestations. (C) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension is aggravated by his ischemic heart disease? For any aggravation found, the clinician should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 2. Afford the Veteran an appropriate VA examination to determine the nature and etiology of his claimed chronic kidney disorder. The Veteran's record, to include a copy of this remand, must be made available to the examiner and all indicated tests should be conducted. Thereafter, the examiner should address the following inquiries: (A) Identify the nature of any current kidney disorder. (B) For each current kidney disorder, is it at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset in, or is otherwise related to, his military service? In offering such opinion, the examiner is advised that the Veteran's STRs are unavailable and no negative inference may be drawn based on such fact. (C) If calculi of the kidney are diagnosed, is it at least as likely as not that such manifested during or within one year of the Veteran's separation from service in March 1985, i.e., by March 1986? If so, please describe the manifestations. In offering such opinions, the examiner must consider and discuss the lay statements of record from the Veteran and his former spouse in which they indicated that he has experienced kidney stones that began in service and continued over time, and the December 1998 treatment record from Kaiser Permanente in which the Veteran reported a 15-year history of experiencing kidney stones. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Spielmann, Jill F. The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.